Functional abdominal cramping pain (FACP) is frequently encountered either independent or in association with a functional gastrointestinal disorder (FGID) and affects patients’ quality of life (QoL) [1, 2]. Despite Rome IV criteria being helpful in diagnosing FGIDs, such as irritable bowel syndrome (IBS), including associated FACP [1, 2], recommendations for the diagnosis and symptomatic management of FACP are lacking. A recent publication by a panel of FGID experts suggested a consensus definition of FACP and provided practical strategies and sequential steps for FACP diagnosis and management .
FACP definition (with or without FGID) and diagnosis
The expert panel suggested a definition for FACP as “the sudden occurrence of mild-to-moderate, undulating, and recurring cramping pain in any part of the abdomen, lasting for seconds to minutes or up to a few hours, in the absence of any ‘red flag’ signs/symptoms of structural organic disease or any strong association with defecation (which might indicate IBS), and typically not significantly interfering with daily activities” .
The expert panel additionally developed three algorithms for physicians, pharmacists, and patients, respectively, to support effective diagnosis and management of FACP .
For FACP diagnosis, it is recommended to initially recognise and exclude ‘red flags’ (alarm symptoms) (Fig. 1) indicative for a structural organic disease, followed by a detailed investigation of family history, medication, pain characteristics and dietary/defecation habits. Physical examination, laboratory tests, psychosocial assessment and abdominal ultrasound may be required in some cases.
Fig. 1. Frequent red flags that may be present in patients with FACP requiring specialist referral . FACP: functional abdominal cramping pain; GI disease: gastrointestinal disease; IBD: inflammatory bowel disease
The self-test algorithm is intended for patients and may help to understand what to do and how to improve self-care.
The probable causes of FACP may be multifactorial and similar to causes of IBS, including psychological stress, impaired mucosal immunity, visceral hypersensitivity, dysbiosis and gut dysmotility [4–7].
Management recommendations for FACP
Patients with mild FACP should be reassured that their pain is not sinister. Avoidance of food that may trigger symptoms and stress reduction may be beneficial. However, some patients may benefit from a probatory short-term treatment with antispasmodics, and an alternative antispasmodic might be useful where adequate relief is not attained by treatment with the first drug. If the pain persists, treatment with analgesics, such as paracetamol, may be beneficial.
Self-management of FACP with over-the-counter medications is recommended for patients with mild, non-persistent symptoms in the absence of red flags.
The algorithm suggested for physicians’ use focuses on the optimal diagnosis and management of FACP in a primary care setting. The recommendations suggested for pharmacists and patients (Fig. 2) support raising awareness for ‘red flag’ symptoms and highlight alternative treatment approaches and may serve as a source of education for pharmacists and patients thus enabling effective self-management of FACP.
Fig. 2. Recommendations for the symptomatic management of FACP by pharmacists, as well as for patient self-care. FACP: functional abdominal cramping pain; IBS: irritable bowel syndrome
For the first time, an FACP working definition was developed and published together with three putative algorithms to facilitate diagnosis and management of FACP, including self-care. When a structural organic disease is ruled out, FACP can appropriately be self-managed with non-prescription drugs, such as antispasmodics.
- Schmulson MJ, Drossman DA. What is new in Rome IV. J Neurogastroenterol Motil. 2017;23:151–63. doi: 10.5056/jnm16214.
- Drossman DA. Functional gastrointestinal disorders: History, pathophysiology, clinical features and Rome IV. Gastroenterology. 2016;150:1262–79.e2. doi: 10.1053/j.gastro.2016.02.032.
- Müller-Lissner S, Andresen V, et al. Functional abdominal cramping pain; expert practical guidance. J Clin Gastroenterol. 2022;56(10):844–52. doi: 10.1097/MCG.0000000000001764. Epub 2022 Sep 23.
- Black CJ, Drossman DA, et al. Functional gastrointestinal disorders: Advances in understanding and management. Lancet. 2020;396:1664–74. doi: 10.1016/S0140-6736(20)32115-2. Epub 2020 Oct 10.
- Barbara G, Feinle-Bisset C, et al. The intestinal microenvironment and functional gastrointestinal disorders. Gastroenterology. 2016;150:1305–18. doi: 10.1053/j.gastro.2016.02.028.
- Ford AC, Sperber AD, et al. Irritable bowel syndrome. Lancet. 2020;396:1675–88. doi: 10.1016/S0140-6736(20)31548-8. Epub 2020 Oct 10.
- Pellissier S, Bonaz B. The place of stress and emotions in the irritable bowel syndrome. Vitam Horm. 2017;103:327–54. doi: 10.1016/bs.vh.2016.09.005. Epub 2016 Nov 23.
Acknowledgements: The authors thank Paula Fontanilla, PhD, for critically reviewing the scientific content of this manuscript and Debayan Goswami, an employee of Sanofi, for providing writing and editorial support.
Conflict of interest: D. Marquez, H. Weigmann and R. Lange are employees of Sanofi.
Disclosure: Sanofi funded medical writing and publication of this manuscript.